CJ Noah Healthcare

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff felt there was a positive culture and despite the current challenges they had the right vision. The registered manager told us, “The main thing is to respect people, we believe in giving back to community, building people. If we put value into staff, they take it to clients, we believe in respect, no matter what background, making sure people feel heard and seen no matter what condition.”

The registered manager was interested in health and social care frameworks and had completed some analysis regarding their staffing challenges. The provider was looking to engage in training arranged by stakeholders and amend their documentation in line with local authority standards.

Leaders did not always have the skills, knowledge and experience to lead effectively. The registered manager had not independently identified and acted in relation to the concerns we found during our assessment.

However, following our feedback the service identified their own learning and development needs and made plans to address these. The registered manager had also started to access support from an independent external service to improve their governance.

Staff felt that the registered manager had all the qualities needed to be a capable leader.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had regular opportunities where they could feedback to the registered manager, and they told us they felt listened to and supported.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider valued their workforce and recognised that the current workload for staff was not fair or sustainable and was working hard to address this.

The provider did not have clear governance processes in place. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
Audits had not been completed in line with their schedule. Some documentation we requested was not available and a lot of documentation was out of date, missing information, not named, dated or signed.
They did not have effective governance systems to monitor care calls.
The registered manager was open about the improvements that were needed in the service. They had sought external support to improve systems. New systems and processes they were introducing needed time to be embedded into practice.
The provider implemented their own service improvement plan following the CQC inspection visit.

The provider sought guidance from partners for improvement. Referrals were made to health professionals when required. The service has linked with another provider to share learning and improve outcomes for people.

Due to a staffing crisis the provider has not been able to focus on continuous learning, innovation and improvement across the organisation and local system. They had not been able to encourage creative ways of delivering equality of experience, outcome and quality of life for people. They were aiming on being able to actively contribute to safe, effective practice and research.